Microsoft word - boy scout permission -- bashore 2012.doc

BSA Troop 152
Boy Scout Permission And Liability Wavier Form
Permission to Attend Bashore Scout Reservation
Vienna, VA
June 2012


Dear Family Member:
Troop 152 will be attending Scout Camp June 24 – June 30, 2012 at Bashore Scout Reservation in central Pennsylvania. Our Adult in Charge is Jim Wolfe (703-220-9231). Other adult leaders include Charlie Brown
(703-819-3536). Your written permission is required before your Scout will be permitted to participate. Please
read this form carefully, sign where indicated, and ask your Scout to return the form to Mr.Wolfe or Mr. Brown. SCOUT'S NAME:
HOME TELEPHONE #:
SCOUT'S HOME ADDRESS:

I. In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is an
voluntary educational institution, and having full confidence that every reasonable precaution will be taken to
ensure the safety and well-being of the Scouts, I agree to my Scout’s participation and waive all claims against the
leaders of this trip and officers, agents, and representatives of the Boy Scouts of America.

II. MEDICAL DISCLOSURE INFORMATION:
Please complete the separate medical forms as well. Note that a separate Medical Form and a Medications
Form (2 forms) are required in addition to this Permission & Liability Waiver. A copy of your insurance
card (front and back) is also required.
The trip leader should be aware of the following medical, or other, problems: _______________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Our Scout is allergic to or highly sensitive to:
____________________________________________________________________________________
____________________________________________________________________________________
Non-prescription and over-the-counter remedies, including the following first-aid medications, may be available
or utilized during this trip. Please indicate which items, if any, your Scout should NOT receive; otherwise, your
Scout may be treated with them as necessary:
Medication Example(s)
Initial one of the following:
Scout may not have ________________
________________________________________
BSA Troop 152
Boy Scout Permission And Liability Wavier Form
Permission to Attend Bashore Scout Reservation
Vienna, VA
June 2012


III. EMERGENCY NAME and NUMBERS:
During this outing, I/we may be reached at:
In the event of an emergency, I understand that every effort will be made to contact me. However, if I cannot be reached, I give permission for any physician, nurse, paramedic, first aid provider or medical facility to treat my Scout with any established, approved medical or surgical procedure necessary to ensure the health and safety of my Scout. This may include hospitalization, anesthesia, surgery or injections of medications. I agree to hold harmless all medical personnel, including those rendering first aid and the leaders of this trip, in this event. My medical insurance carrier is ___________________________________________ Signature of family member giving consent: _____________________________________ Please note that ALL information is required.
Your Scout will not be allowed to board cars
without a complete Permission & Liability Waiver Form.

Source: http://www.troop152camp.org/resources/Boy+Scout+Permission+--+Bashore+2012.pdf